Practice Management

What is “Post-Testing”? The High Cost of Business Efficiency.

Brian Chou, OD, FAAO, with his practice team. Dr. Chou says that efficiency initiatives have to be weighed carefully against the impact on patient care.

Dr. Chou (top row, far right as you are looking at photo) with his practice team. Dr. Chou says that efficiency initiatives have to be weighed carefully against the impact on patient care.

The negative impact of efficiency initiatives that are not executed with care.

By Brian Chou, OD, FAAO

Sept. 13, 2023

In the past few years, optometry has observed many private equity-fueled mergers and acquisitions along with online explorations into remote prescription renewal and contact-lens substitution. What could possibly go wrong?

When business efficiency and profitability are prioritized, it can increase cost to consumers and lower the quality of care. I have spoken to more optometrists, who have sold their business to a private equity affiliate, express misgivings compared to those happy with the overall outcome, including what it meant for their loyal employees and patients. This has occurred in the backdrop of COVID accelerating efforts toward virtual prescription fulfillment and renewal.

In a case involving Hubble Contacts, a woman recently filed a lawsuit against the company claiming that her eye had to be removed due to their “unsafe, defective” contact lenses. This followed in the wake of Hubble’s $3.5 million settlement with the FTC, in which the company, “failed to get or properly verify contact-lens prescription information submitted by customers, sold lenses after prescription verification requests were denied, altered prescriptions from the prescribed brands to Hubble lenses, and failed to maintain required records.”

Poor Patient Outcomes

While corporate consolidators and online retailers often get the bad rap, poor patient outcomes can happen in private optometric practices too. Here, I describe how it occurred in my first group practice.

This practice was top-heavy, with five ODs and only about 10 staff, departing from the industry benchmark of having every OD hour supported by four staff hours. With multiple partners with differing views of management, it was often hard coordinating practice changes. One manifestation of the under-staffing was inconsistency in staff performing the entire battery of preliminary measurements due to time constraints. There were frequent delays in delivering the patient to the doctor. This was exacerbated by a lengthy pre-exam sequence including measurements for blood pressure, macular pigment optical density, nerve fiber analysis and wide-field digital retinal imaging.

The solution implemented by some staff was “post-testing” instead of “pre-testing,” which was performing measurements like screening visual fields and tonometry after the doctor’s exam, regretfully without the doctor reviewing the results. The senior partners condoned this longstanding workflow, until I, as the newest partner, protested after finding a patient who lost his vision from years of doing this.

The tragic case involved a middle-eastern man with Medicaid in his seventies, whose glaucoma was missed for years because his “post-testing” was never reviewed by the attending optometrist until I examined him. For consecutive years, he had elevated IOPs in the mid-20s and screening visual field defects, all missed due to “post-testing.” Clearly, there was a departure from the standard of care with proximate damages.

Multiple Owners Without Cohesion

What would you do if an optometrist within your same practice provided care that did not meet the community standard? I brought the topic up at a partner meeting, drawing a line in the sand for procedural changes. While the senior partners halfheartedly agreed with my proposed abolition of “post-testing,” they allowed it to continue for their own patients, thereby creating operational inconsistency. Consequently, some of the staff felt that I was obstructing their effort to make the practice run more smoothly, not understanding the gravity of a missed diagnosis.

While these staff were well-intentioned to keep patient flow moving, the senior partners condoned “post-testing” and failed to recognize the danger to patient health when important measurements were not reviewed by the doctor. Compounding the issue was a lack of cohesion by all the owners and refusal to hire additional staffing, citing a desire to minimize labor cost.

Maybe I was unconvincing and could have raised the issue better. Still, this preventable tragedy was one of several issues which the multiple owners could not cohesively act upon. Ultimately, I departed in 2011 to create a new group practice with more compatible partners. My new partners and I successfully built and exited group practice ownership in 2017, in the first private-equity optometric acquisition in San Diego.

Still Haunted Today

Today, I am in my third, and last, practice that I intend to own. With 24 years in private practice, I am still haunted by the man with preventable glaucomatous vision loss. He was a vulnerable and pleasant man, for whom English was a second language. I never told him that his vision loss should have been detected sooner. Yet I still harbor lingering frustration that he did not get timely care. I felt the appropriate path was not assigning fault within my own practice, but to make sure he got the glaucoma care he needed prospectively. It was just as important to me to make sure that such a travesty did not happen to another patient.

In Reflection

With the wisdom of time, I now understand that the profit motive is not bad. It is good in the sense that optometric practices need growth to invest in new technology and staffing to provide service sustainably and consistently. The problem arises with profiteering where efficiency is optimized at the expense of what is appropriate for patient care. This maligned behavior is not limited to consolidators and online disrupters, but can even exist in private practice, as I have described. My observation, however, is that private practice owners generally value the well-being of their patients more than the faceless big corporate entities. In a practice with multiple owners, shared values are paramount to coordinate business growth and deliver quality patient care. Choose your business partners carefully!

Brian Chou, OD, FAAO, owns ReVision Optometry in San Diego, Calif., a referral-based keratoconus and scleral lens clinic.



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